Bronchiolitis

PLEASE NOTE in the light of the current coronavirus (COVID-19) situation, we have created an FAQ with COVID-19 information for children, young people and families at GOSH.

Bronchiolitis is a common chest infection that usually affects babies under a year old. Although many get better without treatment, a small number of children will need hospital treatment, occasionally in the intensive care unit. Here we explain the causes and symptoms of bronchiolitis, the treatment available and where to get help.

While bronchiolitis can be caused by various viruses, the most common cause is respiratory syncytial virus – or RSV for short – which, in older children and adults, is the same virus that leads to the ‘common cold’. It usually occurs during our winter months (October to March).

Viruses causing coughs, colds and bronchiolitis are easy to catch and spread when droplets of them are breathed, sneezed or coughed out, or picked up from the skin or hard surfaces, such as door handles and toys.

Similar to a common cold, symptoms include a blocked or runny nose, a cough and a mildly raised temperature. In this case, the bronchioles – smaller breathing tubes that branch off the main passageway to the lungs – produce more mucus than usual and become swollen, leading to a cough and a runny nose.

If the tubes are clogged up with mucus, this may cause breathing problems, meaning your baby is breathing fast and drawing in their muscles around the rib cage. In rare cases, young babies with bronchiolitis may stop breathing for brief periods (this is called apnoea).

The illness usually starts with a mild runny nose or cough, develops over three to five days and then gradually gets better, usually lasting about 10 to 14 days.

Unless your child is very young or has other medical conditions, there’s no need for extra medical advice. However, if your child is struggling to breathe, is difficult to wake or has a blue or pale tinge to their skin, lips or nails, call for medical advice immediately.

You’ll be asked what the symptoms are and when they started, and to describe your child's breathing. For example, is there a wet sounding or chesty cough, runny nose, difficulty breathing and apnoea?

If your child is admitted to hospital, we will usually take a mucus sample from their nose to find out which virus is causing the symptoms. They may also measure the amount of oxygen in the child’s blood (this is called ‘oxygen saturation’), by putting a small probe resembling a sticky plaster around the child’s hand or foot. The result is explained as a percentage. If the number is low (below 92 per cent), this means there isn't enough oxygen in the blood to travel to the body’s tissues and organs and treatment is needed.

Bronchiolitis is caused by a virus, which means antibiotics won’t be effective. Here are some tips on how you can help your child feel a little better:

• Keep them upright as much as possible, to make breathing and feeding easier.
• Make sure they’re in a safe position and unable to fall.
• Tilt the cot’s head upwards to make breathing easier. Try this by raising the cot legs on blocks or putting a pillow under the mattress, although remember never put a pillow or cushion under their head, as this is unsafe.
• Give your child small amounts of fluid frequently to stop dehydration. If they’re drinking around half of their normal fluid intake, they should be safe to stay at home, but if they’re drinking less than this, take them to a doctor.
• Keep an eye on how many wet nappies they have, as fewer of these can be a sign of dehydration.
• Vapour rubs and humidifiers may help and you can also get saline (salt water) drops from a pharmacist to put inside their nostrils, which help to keep the nose clear for breathing and feeding.

Your child may need hospital treatment for bronchiolitis if they are under three months old; were born with a heart defect; have lung disease; were born prematurely (too soon); or have a weakened immune system – either because of a problem they were born with (congenital) or because of medicine they are taking for another problem.

However, many children requiring an intensive care admission won’t fall into these groups.

Around two in 100 infants with bronchiolitis will need to spend some time in hospital, either because they need oxygen treatment to keep their oxygen saturations above 92 per cent, or if they can’t feed from the breast or a bottle because of a blocked nose or difficulty breathing.

There are two treatments commonly used for bronchiolitis:

Nasal cannula oxygen
In this case, oxygen is delivered through a set of short plastic tubes (prongs) placed inside the nostrils. They can also be useful for nurses to draw out mucus from inside the nostrils.

Naso-gastric feeding
If your child is in hospital because they’re not feeding well, a plastic feeding tube may be placed into their mouth or nose, passing down the oesophagus (foodpipe) into the stomach so they can be given their usual milk feeds. If you’re breastfeeding, you'll be asked to express milk to put down the tube, or normal formula feeds can be used.

On rare occasions, if your child has severe difficulty in breathing or is vomiting, we may decide to stop giving feeds for a short period and give fluids by intravenous drip.

After this care, your baby is likely to recover from the virus and, once their oxygen saturations reach above 92 per cent without additional oxygen, and take bottle or breast feeds, you may take them home to recover. The wet sounding cough can continue for many weeks or months after recovery; this isn’t usually anything to worry about.

Very few children require intensive care for bronchiolitis but there are two main reasons why they might need it.

The first is if their oxygen saturations stay low or they’re developing severe breathing problems where the effort to breathe is exhausting them, or if they have apnoea (short periods during which they stop breathing).

The team will support a child through their illness in a number of ways.

• High flow oxygen – a mixture of air and oxygen given at a ‘high flow’ through short plastic tubes placed just inside the nostrils, helping to open your child’s airways so the lungs can add oxygen to their blood.
• Continuous Positive Air Pressure (CPAP) – a mixture of air and oxygen delivered at a high pressure through short plastic tubes or a face mask. The pressure of this mixture opens the child’s airways.
• Intubation and ventilation – if your child’s exhausted or not getting enough oxygen after support from high flow oxygen or CPAP, or if they stop breathing frequently or for long periods, we may suggest putting them on a ventilator or ‘breathing machine’. The ventilator will do their breathing for them while they are unwell, reducing the effort needed to breathe and increasing the oxygen reaching the lungs.
  • A breathing tube, connected to the ventilator, is passed into their airway through their mouth or nose. We will give them medicine to make them sleepy and to reduce movement, so they don’t feel any discomfort. The breathing tube means they won’t be able to cry or make noises while on the machine.
• High-frequency oscillation – if your child’s oxygen saturations remain low, we may suggest a different machine. Its ventilator pushes oxygen in and out of their lungs through the same tube, but is delivered in very short, fast breaths. This kind of ventilator is usually noisy. We may need to give your child medicine to stop them moving during the treatment.

Although bronchiolitis is caused by a virus, some children in intensive care will be given a course of antibiotics to treat any bacterial chest infection that may occur concurrently.

When they’re admitted, we would start your child on intravenous fluids rather than milk feeds, until the most suitable type of breathing support is chosen. Once stable, a naso-gastric tube will be passed into one nostril and down the foodpipe to the stomach, so your child can receive milk feeds.

Nebulisers may help your child breathe. Hypertonic saline, a salt and water solution, can then loosen the lungs’ thick mucus so it may be cleared more easily. Adrenaline nebulisers can also help widen the narrowed airways for short periods.

A physiotherapist may give your child chest physiotherapy, which helps loosen and clear the mucus from the child’s airway.

When we see your child is starting to recover, we’ll start to ‘wean’ them off the breathing machine. When we’re happy your child can breathe well without its help, we’ll try removing the breathing tube and, if they continue breathing well without support, they’ll be discharged.

Bronchiolitis can last up to three weeks, so your child will be transferred back to your local hospital to continue recovering, as they may still need oxygen delivered through nasal prongs for a week or two and help to start feeding from the breast or bottle again. Your local hospital will gradually reduce the amount of oxygen given to your child as they recover and you’ll be able to return home when they’re breathing and feeding well again.

With supportive treatment, the outlook for children who’ve had bronchiolitis is good – it usually gets better with few or no long-term effects.

Some children hospitalised with bronchiolitis may have wheeziness episodes with coughs and colds while they are young. While they may benefit from using inhalers, this doesn’t mean they'll be diagnosed with asthma. If your child had severe bronchiolitis, they may have a cough for several weeks afterwards. We understand you may be concerned, but it’s usually nothing to worry about.

It’s rare for children to die from bronchiolitis; those who do usually have heart or lung conditions, were born prematurely and are still very young when they become infected.